health system performance management quality for better or for worse
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Niek Klazinga, April 27 2010 London LSE/NHS Confederation. Health System Performance Management quality for better or for worse. Accountability Strategic decision making Learning/improvement. Reasons for international comparisons on performance related to quality of care. - PowerPoint PPT PresentationTRANSCRIPT
Dept Social Medicine
Health System Performance Management
quality for better or for worse
• Niek Klazinga, April 27 2010• London LSE/NHS Confederation
Dept Social Medicine
Reasons for international comparisons on performance related to quality of care
• Accountability
• Strategic decision making
• Learning/improvement
Dept Social Medicine
Table 1.1 Conditions under which performance measurementTable 1.1 Conditions under which performance measurement is possible and problematicis possible and problematic
Performance measurement possible Performance measurement problematic
An organization has products An organization has obligations
and is highly value-oriented Products are simple Products are multiple An organization is product-oriented An organization is process-oriented Autonomous production Co-production: products are
generated together with others Products are isolated Products are interwoven Causalities are known Causalities are unknown Quality definable in Quality not definable in performance indicators performance indicators Uniform products Variety of products Environment is stable Environment is dynamic
Source: Managing performance in the public sector. De Bruijn H. (2002), p. 13
Dept Social Medicine
Measurement and Management
• A measure on quality of care does not exist independently• validation is dependent on the use/purpose• Validation is dependent on the boundaries of the universe it
is supposed to signal upon• Measures need to be integrated in management/decision
making mechanisms of government, financiers, managers, professionals and patients
• Apart from reliability and validity, relevance and usefullness are important criteria for selecting quality measures
• As a consequence the users should be involved in the development of the measures
Dept Social Medicine
Health systems performance management
• Health Systems (scope , components and boundaries)
• Performance (objectives on various dimensions such as health results, efficiency and equity – measurement challenges)
• Management (heterogeneous national governance models, integration of performance indicators in management mechanisms)
Dept Social Medicine
Related policies
• Health system sustainability
• Integrated care
• Prevention
• Patient Centered Care
• Equity
• Regulated market
• Incentive structures
7
Conceptual Framework for OECDHealth Care Quality Indicator(HCQI) Project.
(shaded area represents the current focus of the HCQI Project)
Source: Arah OA, et al. A conceptual framework for the OECD Health Care Quality Indicators Project. International Journal Quality Health Care. 2006; Sep 18; Suppl.1:5-13.
7
Dept Social Medicine
Combining various rationalitiesCombining various rationalities
• Public Health• Medicine• Management sciences• Economics• Societal / individual values
Dept Social Medicine
Performance indicators and benchmarking related to mortality data
- avoidable mortality (health system level)
- standardized mortality rates (hospital level)
- limitations of death statistics
Dutch hospital standardised mortality ratios 2001-3(HSMRs) vs hospital
(standardised for age, sex, urgency/readmission, LOS within 50 CCS groups leading to 80% all deaths,excluding small hospitals and those with poor data recording, using year 2000 standard)
0
20
40
60
80
100
120
140
96 35 68 14 83 81 51 25 89 50 103 3 52 44 85 5 78 36 12 100
72 94 13 104
65 33 34 95 101
39 93 82 79 23 61 47 37 20 87 97 45 31 107
19 98 54 102
Hospital number (assigned by BJ)
HSM
Rs (9
5%
CIs
) 2001-2
003
Dept Social Medicine
Performance indicators and benchmarking related to cancer care
• CONCORD study
• Eurocare
• Limitations of cancer registries and limited possibilities for linking with other (administrative) data-bases
1. Programme. 2. Survey.
5.7.1. Cervival cancer screening, percentage of women screened aged 20-69, 2000 to 2006 (or nearest year)
5.7.2 Cervical cancer five-year relative survival rate, 1997-2002 and 2002-2007 (or nearest period)
24.5
38.5
41.7
60.6
62.2
64.0
65.3
69.4
69.6
70.5
70.6
71.0
72.4
72.8
75.6
78.6
79.4
83.5
0 20 40 60 80 100
Japan 2
Hungary 1
Italy 1
Luxembourg 1
Australia 1
Ireland 1
OECD
Belgium 1
Denmark 2
Netherlands 1
Finland 1
New Zealand 1
Iceland 1
France 2
Canada 2
Norway 1
Sweden 1
United Kingdom 1
United States 1
Percentage
2006
2003
2000
27.5
65.5
62.0
54.1
62.9
67.8
66.4
67.3
63.0
63.3
66.0
70.6
61.9
74.1
50.1
57.6
61.3
61.6
63.3
65.6
65.8
65.9
67.0
67.7
69.0
69.0
71.0
71.9
76.5
0 20 40 60 80 100
Poland
United Kingdom
Denmark
Czech Republic
Ireland
OECD (14)
Sweden
Norway
United States
France
New Zealand
Netherlands
Finland
Japan
Iceland
Canada
Korea
Age-standardised rates (%)
2002-2007
1997-2002
Sources: OECD HCQI Data 2009. Survival rates are age standardised to the International Cancer Survival Standards population. OECD Health Data 2009 (cancer screening; mortality data extracted from the WHO Mortality Database and age standardised to the 1980 OECD population). The 95% confidence intervals are represented by H in the relevant charts.
5.7.3. Cervical cancer mortality, females, 1995 to 2005 (or nearest year)
11.4
6.9
6.0
5.7
4.7
4.3
3.7
3.4
3.0
2.9
2.9
2.4
2.4
2.4
2.2
2.1
2.1
2.1
2.0
1.9
1.9
1.7
1.6
1.5
1.3
1.2
1.1
0.7
0.6
0
2
4
6
8
10
12
14
16
181995 2000 2005Age-standardised rates per 100 000 females
1. Programme. 2. Survey.
5.8.1. Mammography screening, percentage of women aged 50- 69 screened, 2000 to 2006 (or nearest year)
5.8.2 Breast cancer five-year relative survival rate, 1997-2002 and 2002-2007 (or nearest period)
19.5
23.8
35.6
47.1
56.2
59.0
59.6
60.1
62.0
62.2
63.5
70.4
70.7
72.5
76.7
78.1
86.2
89.0
0 50 100
Slovak Republic 1
Japan 2
Czech Republic 1
France 1
Australia 1
Belgium 1
Italy 1
New Zealand 1
Hungary 1
Iceland 1
OECD
Luxembourg 1
Canada 2
United Kingdom 1
United States 2
Norway 1
Ireland 1
Finland 1
Netherlands 2
Percentage
2006
2003
2000
60.2
70.8
76.9
72.2
80.5
77.0
76.2
82.6
80.0
82.0
86.1
83.8
85.6
88.6
61.6
75.4
75.5
76.2
77.9
81.1
81.9
82.1
82.4
85.2
86.0
86.1
87.1
88.3
90.5
0 20 40 60 80 100
Poland
Czech Republic
Korea
Ireland
United Kingdom
OECD (14)
Norway
New Zealand
Denmark
France
Netherlands
Finland
Japan
Sweden
Canada
Iceland
United States
Age-standardised rates (%)
2002-2007
1997-2002
Sources: OECD HCQI Data 2009. S urvival rates are age standardised to the International Cancer Survival Standards population. OECD Health Data 2009 (cancer screening; mortality data extracted from the WHO Mortality Database and age standardised to the 1980 OECD population). The 95% confidence intervals are represented by H in the relevant charts.
5.8.3. Breast cancer mortality, females, 1995 to 2005 (or nearest available year)
1. Rates for Iceland and Luxembourg are based on a three-year average.
29.5
28.4
27.0
25.8
25.1
24.9
24.2
23.9
23.1
22.4
22.4
21.5
21.3
21.1
20.8
20.7
20.5
20.3
20.0
19.9
19.5
19.5
19.3
19.3
19.2
16.7
11.0
10.4
5.8
0
10
20
30
40
1995 2000 2005
Age-standardised rates per 100 000 females
France (1997-2002)
Finland (2002-2007)
New Zealand (2002-2007)
Ireland (2001-2006)
5.9.1. Colorectal cancer, five-year relative survival rate, total and male/female, latest period
Netherlands (2001-2006)
Japan (1999-2004)
Canada (2000-2005)
Sweden (2003-2008)
Denmark (2002-2007)
Korea (2001-2006)
Iceland (2003-2008)
United States (2000-2005)
OECD
Norway (2001-2006)
United Kingdom (2001-2006)
Czech Republic (2001-2006)
Poland (2002-2007)38.1
46.8
50.7
52.3
54.4
57.1
57.2
57.8
58.1
58.1
59.8
60.7
60.9
62.0
65.5
66.1
67.3
020406080100Age-standardised rates (%)
34.7
45.6
50.1
50.7
54.2
56.6
56.3
56.9
58.4
59.1
55.2
59.6
59.6
57.0
65.9
69.2
68.7
39.3
48.5
51.5
54.3
54.8
58.5
57.9
59.0
58.2
57.1
64.5
62.3
62.3
62.0
65.1
63.2
66.0
0 20 40 60 80 100Age-standardised rates (%)
Female Male
1. 2000-2005 rather than 2002-2007. 2. 1998-2003 rather than 1997-2002 3. 2001-2006 rather than 2002-2007.
5.9.3. Colorectal cancer mortality, 1995 to 2005 (or nearest year)
5.9.2. Colorectal cancer, five-year relative survival rate, 1997-2002 and 2002-2007
Sources: OECD HCQI Data 2009. Survival rates are age standardised to the International Cancer Survival Standards population. OECD Health Data 2009 (mortality data extracted from the WHO Mortality Database and age standardised to the 1980 OECD population). The 95% confidence intervals are represented by H in the relevant charts.
5.212.113.214.214.414.615.2
16.716.817.017.217.617.618.018.218.819.019.2
19.8
20.620.821.021.4
25.025.3
29.831.031.9
0 10 20 30 40
MexicoGreeceFinland
SwitzerlandUnited States
IcelandKorea
AustraliaSweden
ItalyFranceJapan
United KingdomCanada
LuxembourgAustria
OECD (27)Spain
PortugalGermanyBelgium
NetherlandsPolandIreland
NorwayDenmark
New ZealandSlovak RepublicCzech Republic
Hungary
Age-standardised rates per 100 000 population
2005
1995
20.2
19.8
41.1
48.9
50.2
55.0
54.6
56.9
52.3
57.4
59.6
57.0
60.0
62.5
46.8
52.3
54.4
57.8
57.9
58.1
58.1
60.1
60.7
60.9
62.0
65.5
0 20 40 60 80
Czech Republic 3
Ireland 3
Denmark
Norway 3
OECD (11)
Netherlands 3
Korea 3
Sweden
Canada 1
New Zealand
Finland 2
United States 1
Age-standardised rates (%)
2002-2007 1997-2002
Dept Social Medicine
Performance indicators and benchmarking on care delivered in hospitals
PATH, OECD, many national projects …………
Limitations (administrative) data-bases- Quality of coding practices- Lack of (internationally) standardized procedure codes- Lack of coding of secondary diagnoses- Lack of present at admission coding- Lack of linking via UPI’s- Limitations Electronic Health Records
5.4.1. In-hospital case-fatality rates within 30 days after admission for AMI, 2007
Poland
Austria (2006)
Canada
Italy (2006)
New Zealand
Denmark
Sweden
Iceland
United Kingdom
Norway
Spain
Czech Republic
Korea
Slovak Republic
Luxembourg (2006)
Netherlands (2005)
United States (2006)
Ireland
OECD
Finland
3.6
6.6
4.6
6.4
5.3
6.9
6.6
7.7
5.6
11.0
7.7
8.3
7.0
7.7
9.2
10.9
9.1
10.7
9.9
9.6
2.1
2.9
2.9
3.2
3.3
4.0
4.2
4.5
4.5
4.9
4.9
5.1
5.1
5.3
6.1
6.3
6.6
6.6
7.6
8.1
051015Rates per 100 patients
Age-sex standardised rates
Crude rates 3.3
3.0
2.7
3.0
3.3
3.7
4.0
4.5
4.5
5.6
4.9
5.2
4.9
5.1
5.6
5.8
6.0
8.7
7.0
7.2
0.9
2.9
3.1
3.4
3.2
4.3
4.4
4.5
4.6
4.2
4.9
5.0
5.4
5.5
6.5
6.7
7.1
4.8
8.1
8.9
0 5 10 15Age-standardised rates per 100 patients
Female Male
Source: OECD HCQI Data 2009. Rates have been age-sex standardised to the 2005 OECD population (45+). 95% confidence intervals are represented by H.
5.4.2. Reduction in in-hospital case-fatality rates within 30 days after admission for AMI, 2003-2007 (or nearest year)
8.8
8.3
8.1
7.7
6.5
5.8 6.3 6.9
6.0
5.3
4.8 4.9
4.7
3.7
8.5
3.8
6.6
6.6
6.2
5.2
5.2 5.7
5.2
5.2
3.7 4.2
3.9
3.4
8.1
6.6
6.1
5.1
4.9
4.7
4.5
4.5
4.2
3.3
3.2
2.9
2.9
0
2
4
6
8
10
12
2003 2005 2007
Age-sex standardised rates per 100 patients
5.5.1. In-hospital case-fatality rates within 30 days after admission for ischemic stroke , 2007
5.5.2. In-hospital case-fatality rates within 30 days after admission for hemorrhagic stroke , 2007
5.8
3.6
5.3
5.9
7.4
7.3
7.0
7.7
8.4
6.0
9.0
10.5
9.4
10.8
10.7
11.4
12.1
11.6
12.9
17.4
2.3
2.4
3.1
3.2
3.3
3.7
3.7
3.8
3.9
4.2
5.0
5.6
5.9
6.2
6.3
6.5
6.6
7.5
7.6
9.0
0 5 10 15 20
Iceland
Korea
Denmark
Finland
Norway
Italy (2006)
Austria (2006)
Germany
Sweden
United States (2006)
OECD
Luxembourg (2006)
Netherlands (2005)
Czech Republic
New Zealand
Spain
Ireland
Slovak Republic
Canada
United Kingdom
Rates per 100 patients
Age-sex standardised rates
Crude rates
11.1
13.1
11.3
17.2
19.9
19.7
21.3
20.8
22.5
29.2
23.5
27.3
26.8
27.3
28.2
31.0
26.0
32.1
29.5
32.6
9.5
10.8
11.0
12.8
13.7
14.5
16.7
17.2
19.4
19.8
19.8
23.2
23.8
24.0
24.2
25.2
25.5
26.3
29.3
30.3
0 10 20 30 40
Finland
Austria (2006)
Korea
Sweden
Norway
Germany
Denmark
Italy (2006)
Ireland
Iceland
OECD
Canada
New Zealand
Czech Republic
Spain
Netherlands (2005)
United States (2006)
United Kingdom
Slovak Republic
Luxembourg (2006)
Rates per 100 patients
Age-sex standardised rates
Crude rates
5.5.4. Reduction in in-hospital case-fatality within 30 days after admission for stroke, 2002-2007
5.5.3. In-hospital case-fatality rates within 30 days after admission for ischemic and hemorrhagic stroke, 2007
Source: OECD HCQI Data 2009. Rates are age-sex standardised to the 2005 OECD population (45+). 95% confidence intervals are represented by H in the relevant charts.
1. Based on change from 2002-2003 to 2006. 2. Based on a three-year period only.
AUT
CANCZE
DNK
FIN
DEU
ISL IRL
ITA
KOR
LUX
NLD
NZL
NOR
SVL
ESP
SWE
GBRUSA
R² = 0.54
0
5
10
15
20
25
30
35
0 2 4 6 8 10
Age-sex standardised case-fatality rates for hemorrhagic stroke (%)
Age-sex standardised case-fatality rates for ischemic stroke (%)
33.8
28.6
20.4
18.9
17.8
17.6
15.7
14.1
11.6
9.7
5.5
2.5
1.2
0.5
39.8
14.0
22.9
35.7
16.8
24.2
6.5
16.5
25.6
5.4
1.6
5.0
16.4
0.4
0 10 20 30 40 50
Norway
Austria
Korea 2
Netherlands 2
Germany 2
Finland
Sweden
OECD (13)
Ireland
Spain
Canada 2
Denmark
New Zealand
Luxembourg 1
% decline over period (standardised rates)
Ischemic stroke
Hemorrhagic stroke
Dept Social Medicine
Patient Safety Indicators
• Indicators based on administrative databases
• Adverse event reporting
• Safety culture
24
Indicators– Foreign body left in during procedure (PSI 5) – Catheter related bloodstream infections (PSI 7) – Postoperative pulmonary embolism or deep vein
thrombosis (PSI 12) – Postoperative sepsis (PSI 13) – Accidental puncture and laceration (PSI 15) – Obstetric trauma -- vaginal delivery with instrument
(PSI 18) – Obstetric trauma -- vaginal delivery without
instrument (PSI 19)
Dept Social Medicine
Performance indicators in primary care
• Avoidable hospital admissions
• Lack of comprehensive administrative data-sets
Avoidable hospital admission rates, 2007
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
2.5
3Austria
Belgium
Canada
Denmark
Finland
Germany
Iceland
Ireland
Italy
KoreaNetherlands3
New Zealand
Norway
Poland2
Spain
Sweden
Switzerland
United Kingdom
United States1
Asthma COPD Diabetic acute complications CHF
Note: Data from Austria, Belgium, Italy, Poland, Switzerland and the United States refer to 2006. Data from the Netherlands refer to 2005. 1. Data does not fully exclude day cases. 2. Data includes transfers from other hospitals and/or other units within the same hospitals, which marginally elevate the rates. 3. Data for CHF includes admissions for additional diagnosis codes, which marginally elevate the rate. Source: OECD Health Care Quality Indicators Database, 2009
Dept Social Medicine
Patient experiences
• Service based surveys (CAHPS, Picker, CKZ)• Population based surveys (Eurobarometer, WHO,
CWF)
• Lack of standardization• Lack of research on validation• Lack of research on use
Limitations National Information Infrastructures
• Mortality Statistics • Registries• Administrative Data-Bases• - secondary diagnoses• - present-at-admission coding• - unique patient identifiers• Electronic Health Records• Household and Patient Surveys• Overall: privacy and data-protection
National Information Infrastructures
• Mortality statistics• Registries (cancer)• Administrative
Databases
• Electronic Health Records
• Surveys
• UPI’s/co-morbidity• UPI’s/coding-staging• UPI’s, present-at-
admission codes, secondary diagnoses
• Standardized secondary data-use, privacy concerns
• UPI’s
MA
RQ
uIS
-M
eth
ods
of
Ass
ess
ing R
esp
on
se
to
Qu
ali
t y I
mpro
vem
en
t S
trate
gie
s
Hospital Level
Q.I. Strategies
Ward Level
AIM Deliveries Appendicitis
QI Strategies QI Strategies QI Strategies
Outputs Outputs Outputs
1.2. Analysis of strategies inter-connection
Audit and
internal assessm
ent
Clinical guidelines Perform
a
nce
indicator
s
Org
aniz
atio
nal
qual
ity
Patie
nts’
sa
fety
Patients’ views
51%
Exploratory Factor Analysis
StrategiesLoading weights
- Patient Safety Systems- TQM- Performance Indicators- Systems for getting Patients Views- Clinical guidelines
.857
.822
.694
.581
.578
Dept Social Medicine
Health System Performance Management
• Whole system approach
• Sub-optimization
• Governance/stewardship
• Incentive structure
• Interconnection of strategies on performance indicators, guidelines, safety, TQM, patient experiences